Hospital Name: Arnot-Ogden Medical Center*

PFI # 0116

Complaints:

Complaint Information: 2002
Complaint Investigations Completed 7
Complaints with Statements of Deficiencies (SOD) Issued 3
% of Complaints with SODs Issued 43%
Regional % of Complaints with SODs Issued 28.6%

Areas Cited:

SOD Date Regulatory Citation Areas Cited Date Plan of Correction Accepted
11/13/2002 405.7 PATIENT RIGHTS -HOSPITAL RESPONSIBILITIES 12/11/02
11/13/2002 405.19 EMERGENCY SERVICES GENERAL -POLICIES & PROCEDURES 12/11/02
11/8/2002 405.43 ORDERS NOT TO RESUSCITATE -PRIMARY DECISION-MAKING 12/11/02
11/8/2002 405.43 ORDERS NOT TO RESUSCITATE -POLICIES & PROCEDURES 12/11/02
11/7/2002 405.5 NURSING SERVICES -DELIVERY OF SERVICES 11/27/02
11/7/2002 405.2 GOVERNING BODY -CARE OF PATIENTS 11/27/02

Areas Cited as a Result of Surveys:

DATE OF SURVEY TYPE Areas Cited: Date Plan of Correction Accepted
7/23/2002 - 7/25/2002 TITLE 18 V280 - ER PERIODIC DRILLS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V141 - CHIEF EXECUTIVE OFFICE STAFF TRAINING 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V159 - PT CARE POLICIES DEVELOPMENT AND REVIEW 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V166 - PT CARE POLICIES RX SERVICES 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V187 - WRITTEN LONG TERM PLAN 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V240 - MEDICAL RECORDS ORDERS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V256 - PHYSICAL ENVIRONMENT CONSTR & MAINTAIN FOR SAFETY 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V257 - PHYSICAL ENVIRONMENT FIRE EXT & EVAC PLANS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V258 - PHYSICAL ENVIRONMENT EQUIPMENT PM 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V259 - PHYSICAL ENVIRONMENT FREE OF HAZARDS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V261 - PHYSICAL ENVIRONMENT WATER TREATMENT 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V263 - AAMI-DIALYSATE BACTERIOLOGY 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V112 - GOVERNING BODY HEALTH & SAFETY 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V272 - PREVENT CROSS CONTAMINATION 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V365 - SAMPLE FOR PRESENCE 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V303 - DIALYZER REPROCESSING MANUAL 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V310 - TRAINING CURRICULUM 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V311 - TRAINING DOCUMENTED 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V318 - UTILITY REQUIREMENTS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V325 - PERSONNEL PROTECTION 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V327 - REUSE SUPPLIES SPECS & TESTS 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V328 - INVENTORY CONTROL 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V335 - START TIME FOR REPROCESSING 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V337 - CLEANING 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V344 - FILLING WITH GERMICIDE, CAP CLEANING 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V346 - GERMICIDE CONCENTRATION VERIFICATION 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V347 - EXTERIOR CLEANING 10/30/02
7/23/2002 - 7/25/2002 TITLE 18 V264 - AAMI-CHEM CONTAM 10/30/02